21 - Flu and RSV (Dr. Melissa Kahler)

Melissa Kahler, MD, joins Dr. Arnold to talk about symptoms and treatment of flu and RSV.

If you have a topic you'd like Dr. Arnold to discuss with a guest on the podcast, shoot us an email at stlukescr@unitypoint.org.

Transcript

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Dr. Arnold:
This is LiveWell Talk On...Flu and RSV. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. At least 11 Iowans have died this season from flu-related illness according to the CDC. The flu is considered widespread throughout the state according to the Iowa department of public health. Joining me to talk more about this is Dr Melissa Kahler from UnityPoint Clinic Family Medicine - Westdale. Thanks for taking the time to discuss this today. It's pleasure to have you here.

Dr. Kahler:
Thanks for having me.

Dr. Arnold:
What's your clinic seeing as far as flu? I know influenza, but also the RSV, respiratory syncytial virus is really happening in the community right now, but what, what are you guys seeing?

Dr. Kahler:
So we, in our clinic, we have both family medicine and a few pediatric providers. So we have been seeing a lot of RSV. I mean both in family medicine and pediatrics. We've been seeing a few influenza, a lot more influenza B than influenza A, but definitely not as much influence as respiratory.

Dr. Arnold:
Which opposite of last year, correct?

Dr. Kahler:
Yeah.

Dr. Arnold:
Yeah. Last year. Last year was influenza A?

Dr. Kahler:
Yep.

Dr. Arnold:
This year it's influenza B.

Dr. Kahler:
So far.

Dr. Arnold:
Yeah. Which, which we, we did see Influenza B to kind of come in late last year and then the flu season stopped. But we're having rather benign winter so far. Do you think that's, that's part of it? Cause I have a theory I'm going to follow up with.

Dr. Kahler:
So some headlines came out earlier this week about this maybe being the most deadliest influenza season that there's been in years. So I was looking at that because I feel like we haven't seen that much yet in the clinics. So the CDC tracking goes weekly tracking and through the end of December they saw more, a higher percentage of visits in the clinics for influenza-like illness. And it's widespread in Iowa. Although again, I mean I feel like we haven't seen that much of it, so it is out there. I haven't seen any in like the CDC hasn't made any comments regarding whether anything at this point.

Dr. Arnold:
See, I have this theory that you see a spike in contagious sort of illnesses about seven to 10 days after an event that cloisters people together, and you'll see this in the summer when it's really hot and everybody stays inside. And then after that that heat wave breaks, people start to go out and about and you about seven to 10 days later, the hospital service will look almost like it does in January. And so I always, I think this year the holidays put people in room and grandkids slobber over slobber on grandma and grandpa. And then the nice weather has made that even worse because people are more mobile and out spreading it. That's my theory. That's my theory. I've 25 years, that's the theory I come up with.

Dr. Kahler:
It makes sense.

Dr. Arnold:
Yeah, it does. What are the symptoms of the flu? You know, I did my internship in Detroit, which is venturing into the East coast. And you know, here in Iowa you'd sit, you say terms like the stomach flu and sometimes you say flu. You think a gastrointestinal and that's flu on the East coast is influenza, cough, body aches, not necessarily gastrointestinal, but what, what are the symptoms that you find the most common?

Dr. Kahler:
So Influenza can cause a high fever, body aches, cough, runny nose. I mean adults who have it. I don't know if you've ever had Influenza. I had a one year and that was even after the flu shot, but it was miserable. Like you, I was just so achy. You just feel like you got hit by a bus and it really happens pretty quickly. You can be fine in the morning and by the afternoon feel miserable. So it's really the high fever, cough and achiness that are the main symptoms of influenza.

Dr. Arnold:
Sir William Osler has a description of the prostration that is common where he could make the diagnosis of influenza just by the way the patient was laying in bed from the muscle aches and the weakness.

Dr. Kahler:
Yeah, it really is a pretty typical appearance that people have when they have true influenza.

Dr. Arnold:
The Tamiflu, and I think there's another one on the market this year that, that's a single dose, but I can't recall the name. But does Tamiflu work?

Dr. Kahler:
So since influenza's a virus, it's not going to work like an antibiotic. So Tamiflu is still the most common antiviral that we use. It can shorten the course of symptoms and make the symptoms milder but it's not going to take it away. It's not a cure all within 24 hours by any means. And it's really only indicated for those who are at high risk for complications of influenza. It's not indicated for just the general public if you're otherwise healthy and middle-aged. So people who would be candidates for Tamiflu are people who are really sick and need hospitalization. Kids under two years of age are high risk and then anybody 65 and older. Also, those people who have chronic medical conditions like COPD, lung disease, heart disease, those may be candidates for using Tamiflu also. It really works best to start it within two days of symptoms starting. After that it doesn't have as much effect. So yes, it's available, but it's not really something that we try to use just for everybody.

Dr. Arnold:
And I believe it's relatively expensive. I mean, all medication is expensive, it seems like anymore, but it's relatively expensive.

Dr. Kahler:
It is relatively expensive and there can be pretty significant side effects too. I mean, I've given it to kids who have ended up with hallucinations, which are much worse than dealing with the influenza for a few more days.

Dr. Arnold:
Are you old enough to remember amantadine when we used to give that for influenza?

Dr. Kahler:
No.

Dr. Arnold:
Oh man. The older patients would just become delirious on it. It was, I think amantadine still can be, I don't know. I don't even think it's used in refractory cases of Parkinson's anymore because of the new medications. But yeah, it was a terrible drug and did not work well at all. You, you talked about this is a virus of course, and usually when a physician doesn't know what's going on, they say, well, it's probably viral. That's, you know, that's a joke that the ER doctors always like to throw around, but, but tell us about respiratory syncytial virus, RSV, and how that affects kids and why kids are more susceptible.

Dr. Kahler:
So RSV, we have seen a lot of this year. It's a pretty, it's a very common virus. When I was looking up some research for this, I read that pretty much all kids by the age of two have had RSV. So RSV in you or me who are healthy adults would be a yucky cold cough, kind of feel yuck for a few days, but it can really hit kids and infants hard. It can also hit elderly or people with COPD or lung disease pretty hard. It's very contagious. So there can be outbreaks in daycares, which we've seen earlier this fall and winter. Typically it's a pretty good fever, just copious runny nose, just runny nose and runny nose. So suctioning those babies is a, is a big part of the conservative treatment. And then a yucky cough that's kind of phlegmy. Babies can have wheezing and even difficulty breathing with RSV.

Dr. Arnold:
Do kids do fairly well once they're treated?

Dr. Kahler:
Yes. Yeah. I mean we always worry about the, the babies like the infants, you know, especially six months and under they're really high risk and sometimes there are some kind of asthma like symptoms following illness, but generally they do well and recover completely.

Dr. Arnold:
So I'm a parent, my two year old develops RSV. Do I have to worry about asthma later in life? Is there any predisposition?

Dr. Kahler:
Nope, not usually.

Dr. Arnold:
Okay. And you know, I think the, as a young parent, the first thing is you, you, you don't have the comfortability or the experience to know that things will be okay. And that probably adds some anxiety to it as well.

Dr. Kahler:
And the tricky part with RSV is often day three to four is worse than day one or two. So you know, you, you take them in, you get them seen, we make the diagnosis of RSV or likely RSV and then you take them home and things are getting worse. And that's always anxiety provoking too.

Dr. Arnold:
Well, yeah, kind of like pilot nephritis, you know, you always have to prep the patient that you're going to spike a fever tomorrow, but that's expected. Let's not change stuff and just stay the course. Yeah, I have seen that. Does RSV have antivirals that we can use to treat or is it just supportive care?

Dr. Kahler:
It's just supportive care. So occasionally, I mean if babies are really sick with it, they will need oxygen treatment in the hospital. Most times kids, adults don't need hospitalization for it, but it's really just lots of fluids to make sure you don't get dehydrated, Tylenol or ibuprofen for discomfort. They've actually found, we used to give albuterol to everybody who had it and they found that that's actually not helpful. It's just supportive treatment.

Dr. Arnold:
How long should it, if I have a, again, I'm the young parent, don't have a lot of experience parenting, but, so I, my child's sick. When should I go to the doctor?

Dr. Kahler:
So if you're concerned about the breathing I mean, fevers are, fevers are good, fevers help fight off whatever illness we're fighting. So a fever in and of itself is okay. No, but if they start to really work hard to breathe, we call our attractions. But if they kind of stuck in their belly or around their ribs when they're breathing or wheezing or you just can't get them comfortable, those are all reasons to be seen.

Dr. Arnold:
Okay. And bring them in for that. And we'll say it on this podcast. We've said them on the others. If you ever have a concern about a loved one or yourself, go see the physician and you know, and we'll, we'll sort it out.

Dr. Kahler:
And sometimes for first time new parents too. I mean, that's just scary. It's, it's better to have somebody else lay eyes on and reassure too.

Dr. Arnold:
Yeah. You always want to reassure confidently and give them a treatment plan. I don't know. Do you have children, don't you?

Dr. Kahler:
I do.

Dr. Arnold:
Yeah, I, you know, I would, I think every physician has a story where like their child was sick and you know, it's at the end of the day. And the last thing you want to do is see another ill patient when you get home. And you know, there's, there's plenty of physicians out there that have misdiagnosed an appendicitis or delayed diagnosis cause you know, they're kids, ah you're just constipated, you know, go, go play. And so, so even us physicians have some anxiety with parenting. It's not easy. And is RSV, we do have testing for that. The, the FilmArray and, and we won't get into specifics that it's at the, not the broadcast to do that, but do you always get the testing or sometimes you just, okay, this is so rampant right now. There's no reason to test.

Dr. Kahler:
Correct. I mean, especially once we saw it a few weeks ago that it was really increasing. Again, I mean, just like you can kind of tell when an adult has influenza, you can kind of tell by listening to a kid if it's likely RSV. So, I mean, we know that we treat it conservatively if we're certain that there's no pneumonia or bacterial infection and it doesn't always need to be tested,

Dr. Arnold:
The flu season will start and then they'll say, Oh, well, it's kind of plateaued. I'm like, well, I don't, I don't know if you can say that just yet because a lot of clinicians are not testing for it and sometimes it's, you know, we here at St. Luke's, we use the testing that comes back in the lab to kind of gauge where we're at. We report that out and you know, and, and, and direct our, our treatment and masking and isolation, all that based upon that. But there might be a lag there. I always say, because you know, if it's the 10th patient in a row that has the same symptoms, you're going to treat it empirically and not necessarily test.

Dr. Kahler:
Right. And I know the CDC also with influenza, they track percentage of visits for influenza like illness. So even if there's not testing, we should, they should be kind of following that also.

Dr. Arnold:
Now in the clinic, did you, this year with the flu shot, did you differentiate between the high dose and low dose?

Dr. Kahler:
Yes. So everybody 65 and over gets the high dose. And they found that that just gives them a little bit better immunity right after the shot and throughout the, the season. And then everybody under 65 would get the regular quadrivalent. Yep.

Dr. Arnold:
The annals of internal medicine just had a study about transplant patients that on transplant medication should receive the high dose and that's a new recommendation.

Dr. Kahler:
Which yeah, I mean that makes sense with their immunosuppression.

Dr. Arnold:
The, the flu shot, I, I guess we probably could do a whole, and we have done a little bit within infectious disease at one point, but people are always reluctant to get the influenza vaccination, not everyone, not everyone. I shouldn't, I shouldn't generalize like that, but let's walk through some of the myths. You know, the first myth is that the flu shot cannot give you the flu. Correct?

Dr. Kahler:
Correct.

Dr. Arnold:
It's a dead virus. It shouldn't.

Dr. Kahler:
Right. But that, I mean, over and over again, that's the number one myth that I hear. And I think people have different conceptions of that too. So some people don't realize that it is a dead virus and then it cannot give you influenza. You know, a lot of people just tell me, the year I got the flu shot, I had more coughs and colds and illness than I've ever had before. Which really, there's, there's no correlation between getting the flu shot and a regular cough and cold. So yes, that's over and over, that's the myth that I hear.

Dr. Arnold:
Yeah. Once something gets into the urban lore, then it's hard to get it out. I mean, autism and vaccinations, you know, 10,000 patients in the study said there is no association, but it's still there. It's still, yeah. In the, and I can understand people have some trepidation about what are you injecting into me or my children. I get it, you know, but influenza vaccinations work. I had a patient, he was, I took care of him, he was in his nineties but he was like eight or nine years old during the influenza of 1918 after the Spanish flu. And he would said he would, he would ride with the town doctor during the day. This was in North Dakota, from town to town, house to house to keep him awake while he was driving because the doctor was, you know, the only town doctor. And he said you'd go to a farmstead and the family would all be with the flu. You come back like two days later, nobody answered the door because they'd all passed away. You know. And that doesn't happen anymore because we have the influenza vaccination. And so when people think that the flu shot doesn't work, well we haven't had a pandemic. We were supposed to have one in the late eighties and it never happened because of our vaccination.

Dr. Kahler:
Yeah. And it's, I mean, so the CDC says in general, the influenza shot decreases your risk of having flu by 40 to 60%. So it's not 100%. Of course we would want, you know, yes, we would all love that. If we saw it, 90 to a hundred percent, it's probably never going to be there. But I mean, that's a pretty good risk reduction. We also know that it decreases mortality, hospitalizations and that people tend to have milder disease, you know, even if they do get influenza after the shot.

Dr. Arnold:
And then I think healthcare providers are sometimes, because you do have some carry over of antibodies from one year to the next, right in one strain of the next. And yeah, I think sometimes as physicians, I am, early in my career I wasn't really good about getting it every year. Too busy and just blew it off. Really. Not that I didn't believe in it, but just, just to get it done. Because I would think to myself, I'd never get the flu. Well it's just because I've been around it so much that you never really, you might get a little ill, but it's transient and you don't, you're not prostrated out in bed like you talked about earlier. But you know, I mean we do achieve almost a hundred percent vaccinations with the medical staff now, but that was not always the case. And I don't think it was disbelief in the vaccine. It was just not making that priority. And I think it should be as a health care worker.

Dr. Kahler:
When I tell patients that too, you know, there, there just has to be some carry over. You know, and I've been practicing for 12 years and I've had influenza probably a relatively mild case one time and I'm around it every single year for months at a time, you know, so there's, there's gotta be some good immunity year after year,

Dr. Arnold:
But you're never the sickest as a physician, except when you do your pediatric rotation as a medical student, you know, that is, yeah, that is the most ill you'll ever be in your life. You know? I mean, I, there should be hazard pay for daycare workers because they're exposed to some of the most virulent strains of whatever might be out in the community. Why did you become a family physician? I remember when you were a resident. That's how old I am or how young you are. I should say but, but why, why family practice? Why Cedar Rapids?

Dr. Kahler:
Why family practice? So, I mean, even starting medical school, I, I love the variety. I love taking care of the whole family, from babies to the grandparents and knowing all of them and how their, how their family interacts. And I just love that part of it. My days are never boring. I mean, there's always a large amount of different conditions and diagnosis that I treat. Cedar Rapids. So we grew up around this area, not right in Cedar Rapids. I went to school at Iowa and then did my residency here in Cedar Rapids and we just kind of fell in love with it and stayed.

Dr. Arnold:
Well, it's my home town. I can't can't blame you for that. Really great information. Thanks so much for taking the time to talk. Again, this was Dr. Melissa Kahler from UnityPoint Clinic Family Medicine - Westdale. If you have a topic you'd like to suggest for a talk on podcast, shoot us an email at stlukescr@unitypoint.org. And we encourage you, tell your family, friends, neighbors, strangers about our podcast. Until next time, be well.